“Trombosi ed Emostasi in Ostetricia e Ginecologia” Varese, 22 settembre 2012 Aula Magna-Dipartimento di Biologia-Università degli Studi dell’Insubria-Via Dunant, 3-Varese- Prevenzione del TEV in Chirurgia Ginecologica: Eparine a basso peso molecolare Luigi Steidl Centro Trombosi ed Emostasi U.O. di Medicina Interna I Ospedale di Circolo Varese Il rischio peri-operatorio standard Pre-operatorio Intra-operatorio Post-operatorio Rischio emorragico -- +++* - +* Rischio trombotico -- +++* +++* *Secondo la procedura chirurgica Prevenzione del TEV in Chirurgia Ginecologica: Eparine a basso peso molecolare Premessa Dimensioni del problema Metodi di tromboprofilassi farmacologica e non farmacologica Stratificazione del rischio trombotico ed emorragico Tempi e dosi Linee Guida Prevenzione del TEV in Chirurgia Ginecologica • Dati estrapolati e derivati da studi in pazienti di chirurgia generale e addomino-pelvica • Mancanza di dati recenti specifici in ginecologia • Bilancio tra benefici (riduzione dell’incidenza di TEV) e costi in termini di eventi emorragici Horlander KT , et al. Arch Intern Med. 2003; 163 (14): 1711-1717 Geerts WH, Bergqvist D, Pineo GH, et al., Chest 2008;133: 381-453 Incidenza di tromboembolismo venoso nei pazienti ricoverati Pazienti internistici Chirurgia generale Chirurgia ginecologica Chirurgia urologica Neurochirurgia Chirurgia ortopedica maggiore Traumi maggiori Terapia intensiva Trauma spinale 10-20% 15-40% 15-40% 15-40% 15-40% 40-60% 40-80% 10-80% 50-100% National Institute for Health and Clinical Excellence. Reducing the risk of venous thromboembolism in inpatients undergoing surgery. NICE clinical guideline No. 46:1–160. Available at: http://www.nice.org.uk/CG046. Accessed March 31, 2008 Levels of Thromboembolism Risk and Recommended Thromboprophylaxis in Hospital Patients Lassen MR, Borris LC, Backs S, et al. Blood Coagul Fibrinolysis 1999; 10(suppl 2):S45–S51 Prevention of Venous Thromboembolism The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy Chest 2004;126:338S-400S Risk factors for VTE Surgery Trauma (major or lower extremity) Immobility, paresis Malignancy Cancer therapy (hormonal, chemotherapy, or radiotherapy) Previous VTE Increasing age Central venous catheterization Pregnancy and the postpartum period Estrogen-containing oral contraception or hormone replacement therapy Selective estrogen receptor modulators Acute medical illness Rationale for Thromboprophylaxis in Hospitalized Patients W. H. Geerts et al., CHEST 2004; 126:338S–400S Prevenzione del TEV in Chirurgia Calze elastiche Compressione pneumatica intermittente Eparina non frazionata a basse dosi EBPM a dosi profilattiche Fondaparinux Ac. Acetilsalicilico Filtri cavali Sorveglianza periodica con c-US Advantages and Limitations of Mechanical Thromboprophylaxis Modalities Advantages • Do not increase the risk of bleeding • Can be used in patients at high bleeding risk • Efficacy has been demonstrated in a number of patient groups • May enhance the effectiveness of anticoagulant thromboprophylaxis • May reduce leg swelling Limitations • • • • • • • • • • • Not as intensively studied as pharmacologic thromboprophylaxis (fewer studies and smaller) No established standards for size, pressure, or physiologic features Many specific mechanical devices have never been assessed in any clinical trial Almost all mechanical thromboprophylaxis trials were unblinded and therefore have a potential for bias In high-risk groups are less effective than anticoagulant thromboprophylaxis Greater effect in reducing calf DVT than proximal DVT Effect on PE and death unknown May reduce or delay the use of more effective anticoagulant thromboprophylaxis Compliance by patients and staff often poor Trials may overestimate the protection compared with routine use Cost: associated with purchase, storage, dispensing, and cleaning of the devices, as well as ensuring optimal compliance A brief history of anticoagulant therapy Unfractionated heparins: antithrombin (AT)-dependent inhibition of Factor Xa and IIa in a 1:1 ratio Parenteral Vitamin K antagonists: indirectly affect synthesis of multiple coagulation factors Oral Parenteral 1940s Low molecular weight heparin: AT-dependent inhibition of Factor Xa >IIa Parenteral Direct Factor IIa inhibitors Parenteral Indirect Factor Xa inhibitors 1930s 1980s 1990s 2000s Direct Factor IIa inhibitors Oral Direct Factor Xa inhibitors Oral Alban, Eur J Clin Invest 2005 Link, Circulation 1959 REGIMENS TO PREVENT VENOUS THROMBOEMBOLISM Surgical conditions LMWH Enoxaparin 40 mg sc once daily Nadroparin 2850-3400 U sc once daily Dalteparin 2500-5000 U sc once daily Danaparoid 750 U sc q12h LDUH Heparin 5000 U sc q8-12h Nicolaides et al, Int Angiol, 1997 Risk Stratification in General, Abdominal-Pelvic, Gynecologic Surgery Risk of VTE procedure-specific factors low-risk procedures laparoscopic surgery, appendectomy, transurethral prostatectomy, inguinal herniorrhaphy, unilateral or bilateral mastectomy high-risk procedures Open-abdominal and open-pelvic procedures Cancer surgery patient-specific factors age, prior VTE, cancer, anesthesia >2 h, bed rest >4 days, male sex, sepsis, pregnancy or postpartum state, central venous access Andtbacka RH , et al. Ann Surg . 2006 ; 243 ( 1 ): 96 – 101 Clarke-Pearson DL, et al.Obstet Gynecol . 2003 ; 101 ( 1 ): 157 - 163 Caprini Risk Assessment Model (modified) VTE risk categorization: •very low (0-1 point) •low (2 points) •moderate (3-4 points) •high (≥5 points) Caprini JA . Dis Mon . 2005 ; 51 ( 2-3 ): 70 – 78 Caprini JA, Arcelus JI, Hasty JH, Tamhane AC, Fabrega F. Semin Thromb Hemost . 1991 Rogers Risk Assessment Model VTE risk categorization: •low (< 7 points) •moderate (7-10 points) •high (> 10 points) Rogers SO Jr , Kilaru RK , Hosokawa P , Henderson WG , Zinner MJ , Khuri SF. J Am Coll Surg. 2007; 204 (6): 1211-1221 Risk Assessment Models (RAM) Limiti: • Mancanza di validazione clinica • Time-consuming Baseline Risk and Risk Factors for Major Bleeding Complications • Meta-analysis of seven randomized trials of LMWH in absence of prophylaxis: – major bleeding in the control groups: 1.2% (95% CI, 0.9%-1.7%) Mismetti P, et al. Br J Surg . 2001 ; 88 ( 7 ): 913 - 930 • Meta-analysis of thirty-three randomized trials of LMWH in absence of prophylaxis: – major bleeding in the control groups:Leonardi 0.7% MJ, (95% CI, 0.92%-1.57%) et al. Arch Surg . 2006 ; 141 ( 8 ): 790 - 797. • Bleeding risk with LMWH: – Major bleeding (RR, 2.03; 95% CI, 1.37-3.01) – Wound hematoma (RR, 1.88; 95% CI, 1.54-2.28) Sweetland S, et al. Million Women Study Collaborators. BMJ . 2009 ; 339 DVT After Laparoscopic Procedures Higher VTE Risk in Cancer Surgery Patients Increased age Longer immobilisation (pre and post operatively) Associated treatment with Radiotherapy Chemotherapy Central venous catheters Longer operative procedures Traumatic and extensive surgery Bergqvist D. Thromb Res 2001; 102:V209-13. The risk of postoperative DVT is increased after general surgery for cancer Cancer patients Non-cancer patients Kakkar et al. 1970 24/59 (41%) 38/144 (26%) Hills et al. 1972 8/16 (50%) 7/34 (21%) Walsh et al. 1974 16/45 (35%) 22/217 (10%) Rosenberg et al. 1975 28/66 (42%) 29/128 (23%) Sue-Ling et al. 1986 12/23 (52%) 16/62 (26%) Allan et al. 1983 31/100 (31%) 21/100 (21%) 9/37 (22%) 13/53 (24%) Multicenter Trial 1984 All 128/346 (37%) 146/738 (20%) Prandoni P et al. Haematologica 1999;84:437-45 Outcomes in Cancer Patients Undergoing Surgery* Meta-analysis of all randomised studies comparing LMWH and UFH in patients undergoing general surgery (18 – 46,000 patients) Outcome Cancer surgery DVT Non-Cancer surgery 6% 4.8% Clinical PE 0.8% 0.4% Clinical VTE 1.8% 1.2% Death 4.8% 1.5% Major haemorrhage 8.1% 2.7% * Patients all receiving unfractionated heparin Mismetti P, et al. Br J Surg 2001; 88: 913-30. Rischio di TEV Incidenza di TEV nel tempo ? Tempo Chirurgia Dimissione Standard duration of thromboprophylaxis after general surgery In thromboprophylaxis studies in general and abdominal-pelvic surgery 7-10 days Geerts WH et al. Chest 2004;126;338S-400S Standard duration of thromboprophylaxis after general surgery In thromboprophylaxis studies in general and abdominal-pelvic surgery -oncology setting- 4 weeks Bergqvist D, Agnelli G, Cohen AT, et al. N Engl J Med 2002; 346:975–980 International guidelines Nessuna grande variazione rispetto a edizioni precedenti (2001-2004-2008) Scomparsa del capitolo specifico sulla Chirurgia ginecologica ricompreso nella chirurgia generale Prevention of VTE in Non-orthopedic Surgical Patients ANTITHROMBOTIC THERAPY AND PREVENTION OF THROMBOSIS, 9TH ED: ACCP GUIDELINES Chest 2012;141:227S-277S 3.6.1. For general and abdominal-pelvic surgery patients at very low risk for VTE (<0.5%; Rogers score, <7; Caprini score, 0), we recommend that no specific pharmacologic (Grade 1B) or mechanical (Grade 2C) prophylaxis be used other than early ambulation. 3.6.2. For general and abdominal-pelvic surgery patients at low risk for VTE ( 1.5%; Rogers score, 7-10; Caprini score, 1-2), we suggest mechanical prophylaxis, preferably with IPC, over no prophylaxis (Grade 2C) . 3.6.3. For general and abdominal-pelvic surgery patients at moderate risk for VTE (3.0%; Rogers score, >10; Caprini score, 3-4) who are not at high risk for major bleeding complications, we suggest LMWH (Grade 2B), LDUH (Grade 2B), or mechanical prophylaxis, preferably with IPC (Grade 2C), over no prophylaxis. Prevention of VTE in Non-orthopedic Surgical Patients ANTITHROMBOTIC THERAPY AND PREVENTION OF THROMBOSIS, 9TH ED: ACCP GUIDELINES Chest 2012;141:227S-277S 3.6.4. For general and abdominal-pelvic surgery patients at moderate risk for VTE (3.0%; Rogers score, >10; Caprini score, 3-4) who are at high risk for major bleeding complications or those in whom the consequences of bleeding are thought to be particularly severe, we suggest mechanical prophylaxis, preferably with IPC, over no prophylaxis (Grade 2C) . 3.6.5. For general and abdominal-pelvic surgery patients at high risk for VTE (6.0%; Caprini score, ≥5) who are not at high risk for major bleeding complications, we recommend pharmacologic prophylaxis with LMWH (Grade 1B) or LDUH (Grade 1B) over no prophylaxis. We suggest that mechanical prophylaxis with ES or IPC should be added to pharmacologic prophylaxis (Grade 2C) . Prevention of VTE in Non-orthopedic Surgical Patients ANTITHROMBOTIC THERAPY AND PREVENTION OF THROMBOSIS, 9TH ED: ACCP GUIDELINES Chest 2012;141:227S-277S 3.6.6. For high-VTE-risk patients undergoing abdominal or pelvic surgery for cancer who are not otherwise at high risk for major bleeding complications, we recommend extended-duration pharmacologic prophylaxis (4 weeks) with LMWH over limited-duration prophylaxis (Grade 1B) . 3.6.7. For high-VTE-risk general and abdominal-pelvic surgery patients who are at high risk for major bleeding complications or those in whom the consequences of bleeding are thought to be particularly severe, we suggest use of mechanical prophylaxis, preferably with IPC, over no prophylaxis until the risk of bleeding diminishes and pharmacologic prophylaxis may be initiated (Grade 2C) . Prevention of VTE in Non-orthopedic Surgical Patients ANTITHROMBOTIC THERAPY AND PREVENTION OF THROMBOSIS, 9TH ED: ACCP GUIDELINES Chest 2012;141:227S-277S Rischio trombotico Rischio Durata emorragico Profilassi farmacologica Profilassi non farmacologica Molto basso Nessuna(1B) Nessuna (2C) Basso Nessuna(1B) CPI (2C) o CE Moderato Basso EBPM o ENF BD (2B) CPI (2C) Moderato Alto Nessuna CPI (2C) Alto Basso EBPM o ENF BD (1B) + CE o CPI (2C) Alto (+neoplasia) Basso Alto Alto 4 settimane EBPM (1B) Nessuna CPI: compressione pneumatica intermittente; CE: calze elastiche; EBPM: eparine a basso PM; ENF BD: eparina non frazionata a basso dosaggio CPI (2C) sino a rischio emorragico basso Prevention of Venous Thromboembolism American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) CHEST 2008; 133:381S–453S 2.3.1. For low-risk gynecologic surgery patients who are undergoing minor procedures and have no additional risk factors, we recommend against the use of specific thromboprophylaxis other than early and frequent ambulation (Grade 1A). 2.3.2. For gynecology patients undergoing entirely laparoscopic procedures, we recommend against routine thromboprophylaxis, other than early and frequent ambulation (Grade 1B). 2.3.3. For gynecology patients undergoing entirely laparoscopic procedures in whom additional VTE risk factors are present, we recommend the use of thromboprophylaxis with one or more of LMWH, LDUH, IPC, or GCS (Grade 1C). Prevention of VTE in Non-orthopedic Surgical Patients ANTITHROMBOTIC THERAPY AND PREVENTION OF THROMBOSIS, 9TH ED: ACCP GUIDELINES Chest 2012;141:227S-277S 3.6.8. For general and abdominal-pelvic surgery patients at high risk for VTE (6%; Caprini score, ≥5) in whom both LMWH and unfractionated heparin are contraindicated or unavailable and who are not at high risk for major bleeding complications, we suggest low-dose aspirin (Grade 2C) , fondaparinux (Grade 2C) , or mechanical prophylaxis, preferably with IPC (Grade 2C) , over no prophylaxis 3.6.9. For general and abdominal-pelvic surgery patients, we suggest that an IVC filter should not be used for primary VTE prevention (Grade 2C) . 3.6.10. For general and abdominal-pelvic surgery patients, we suggest that periodic surveillance with VCU should not be performed (Grade 2C) . All women who have had an emergency caesarean section (category 1–3) should be considered for thromboprophylaxis with LMWH for 7 days after delivery. All women who have had an elective caesarean section (category 4) who have one or more additional risk factors (such as age over 35 years, BMI greater than 30) should be considered for thromboprophylaxis with LMWH for 7 days after delivery. Prevention of VTE in Non-orthopedic Surgical Patients ANTITHROMBOTIC THERAPY AND PREVENTION OF THROMBOSIS, 9TH ED: ACCP GUIDELINES Chest 2012;141:227S-277S 6.2.1. For women undergoing cesarean section without additional thrombosis risk factors, we recommend against the use of thrombosis prophylaxis other than early mobilization (Grade 1B). 6.2.2. For women at increased risk of VTE after cesarean section because of the presence of one major or at least two minor risk factors, we suggest pharmacologic thromboprophylaxis (prophylactic LMWH) or mechanical prophylaxis (elastic stockings or intermittent pneumatic compression) in those with contraindications to anticoagulants while in hospital following delivery rather than no prophylaxis (Grade 2B). 6.2.3. For women undergoing cesarean section who are considered to be at very high risk for VTE and who have multiple additional risk factors for thromboembolism that persist in the puerperium, we suggest that prophylactic LMWH be combined with elastic stockings and/or intermittent pneumatic compression over LMWH alone (Grade 2C) . Conclusioni (take home messages) Nessuna grande novità nel panorama recente Indicazioni personalizzate sulle RAM Rischio di sanguinamento Efficacia e sicurezza delle EBPM Non ancora studiati i Nuovi Anticoagulanti Orali (NAO) Contraccezione ormonale e HRT e rischio tromboembolico Take-home messages [1] La COC e’ un fattore di rischio per TEV? Si (OR: 5) E la contraccezione per altra via di somministrazione? Si (≠IUD medicato, impianto sc, progestinico iniettabile) Se si, è un fattore di rischio minore o maggiore? Minore (20-40aa=baseline: 1/10000COC: 3-6/10000) E’ utile lo screening trombofilico a tutte le donne? No, solo “famiglie trombofiliche” E’ anche un fattore di rischio cardiocerebrovascolare? Si (OR: 2) E la terapia ormonale sostitutiva? Si (OR: 3,5) Esami di Trombofilia Venosa Anticorpi Antitrombina antifosfolipidi (ACA + Proteina C ed S antiB2GPI) + LAC della (aPTT + DVVRT) coagulazione FII mutazione G20210A FV Leiden Omocisteina Eseguire la determinazione prima della somministrazione di contraccettivi !! FVIIIC Approccio razionale alla prescrizione della contraccezione ormonale: Take-home messages [1] 1- Tipo del contraccettivo ed entità del rischio : L’estradiolo è la componente di un COC che impatta maggiormente sul rischio di TEV. Il rischio di TEV è strettamente correlato e direttamente proporzionale alla dose di EtinilEstradiolo. I diversi progestinici modificano l’effetto protrombotico degli estrogeni. 2- I progestinici di III generazione hanno un RR doppio di TEV rispetto a quelli di II Generazione. 3- Non ci sono chiare evidenze sul minor rischio di TEV di COCs con estrogeni naturali e/o COC somministrati per vie alternative (ring-cerotto), benchè senz’altro i suddetti COCs abbiano un migliore profilo metabolico. 4- Screening trombofilie mirato e non su larga scala! La gravidanza puo’ già in donne sane e senza fattori di rischio aggiuntivi, essere considerata uno stress test sul sistema coagulatorio e una storia ostetrica negativa per TEV in queste donne puo’ essere un’indicazione sufficiente alla prescrizione di OC. 5- Controindicazione alla prescrizione di COC nelle pazienti con pregresso TEV! Take-home messages [2] Consigli pratici prima della prescrizione della COCs: • • Accurata anamnesi personale & familiare 2008 Consensus Conference SNLG “Prevenzione delle complicanze trombotiche Misurazione PA • Non si raccomanda né prima di prescrivere un contraccettivo né durante l’uso l’esecuzione routinaria di : -Esami ematochimici generici -Test generici di coagulazione -Test specifici per trombofilia • Partire con CO a basso dosaggio (20-30 γ) + progestinico di II generazione • Attenzione a fumo ed obesità!! associate all’uso di E/P nell’età riproduttiva Tutto il resto non è indispensabile.